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A 36-year-old man with a red eye
Digital Journal of Ophthalmology 2008
Volume 14, Number 9
April 13, 2008
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Drew Chronister, M.D. | University of Pittsburgh Eye and Ear Institute
Evan Waxman, M.D. | University of Pittsburgh Eye and Ear Institute
Differential Diagnosis
We considered multiple inflammatory, infectious, and neoplastic causes in our patient with panuveitis. Of all the inflammatory causes of panuveitis, sarcoidosis may be the most common, but it affects African-American patients much more commonly than Caucasian patients. The keratic precipitates are classically mutton-fat and not fine as in this case. Vogt-Koyanagi-Harada (VKH) disease causes a diffuse granulomatous uveitis with a flu-like prodrome. Typically, however, it affects dark-skinned patients, particularly Asians or American Indians.(1) Also, it is often associated with central nervous system or dermatologic signs including hearing loss, seizures, meningismus, focal neurologic deficits, alopecia, or vitiligo, all of which our patient did not have. When considering the diagnosis of sympathetic ophthalmia, the patient indeed had the necessary history of a penetrating eye trauma. While the majority of sympathetic ophthalmia cases present within the first year, there have been cases presenting as long as 66 years after the trauma.(2) A rare cause of panuveitis, Behcet disease requires recurrent oral and/or genital ulcers in addition to uveitis (often with a hypopyon) for diagnosis.(1) Our patient did not present with any of these findings other than the uveitis. A white dot syndrome was considered and of all the disease entities that cause white dots, the fundus lesions were most similar to those found in acute posterior multifocal placoid pigment epitheliopathy (APMPPE). This disease does occur in young healthy adults with a viral prodrome; however, our patient had more anterior chamber cells than would be expected in APMPPE.

Other than working as a prison guard, our patient gave no other risk factors or history of exposure to any possible infectious cause. He also did not show any systemic signs of illness at the time he was evaluated. Nevertheless, we considered syphilis, tuberculosis, toxoplasmosis, endogenous endophthalmitis, Lyme disease, and toxocariasis as possible infectious causes that needed to be ruled out.

Lastly, we considered neoplastic masquerade syndromes as they constitute 2-3% of all uveitis cases seen at a tertiary uveitis center.(1) Primary CNS lymphoma is the most common cause; however, this neoplasm presents in a much older population than our patient. Leukemia was also unlikely and more commonly presents as a retinopathy. Metastases represents the most common intraocular malignancy in adults and most often presents as choroidal metastases with vitritis,(1) but our patient had no history of a primary tumor.